APPLICANT QUOTE ONLY PLEASE BIND
Name Of Applicant(s):
Are there more than 2 registered owners? / YES NO
Risk Location Address:
City: Prov: PC:
DWELLING
Type of Building:
Detached Home Semi-Detached Duplex Triplex Fourplex End Low (Townhouse) Inside Low (Townhouse)
Log Home Mobile Home (fully blocked, skirted + connected to utilities) Other (describe):
Construction:
Concrete Block/Masonry Stucco – Wood Frame Vinyl Siding – Wood Frame
Wood Siding – Wood Frame Concrete Fiberboard – Wood Frame Brick Veneer – Wood Frame
Stone Veneer – Wood Frame Solid Log Solid Brick Solid Stone Other (describe):
Foundation: Concrete Post & Pier Brick Stone Treated Lumber
Year Built: / Square Footage: / No. of Stories: No. of Kitchens:
How many amps is the electrical system? Under 60 Amps 60 Amps 100 Amps Over 100 Amps
Electrical System Details (check all that apply): Circuit Breakers Fuses Aluminum Knob & Tube
Year of last major update to the electrical system:
Type of Plumbing: Copper PEX Galvanized Steel Polybutylene Cast Iron Other/Combined:
Year of last major update to the plumbing system:
Roof Material: Asphalt Shingles Metal Panel Flat Deck / Tar & Gravel Cedar Shingles / Shakes Metal Shingles Clay Tile / Slate
Year of Roof Update:
HEATING: Year of Heating Update: / Note: if there is an oil tank or wood heat, an Oil Tank or Wood Heat Questionnaire is required.
Primary Heat: / Primary Heat Fuel Type:
Auxiliary Heat: / Auxiliary Heat Fuel Type:
Does the property have operational smoke detectors? / YES NO
Is there a swimming pool on premises? / YES NO
Distance to Fire Hydrant: / Distance to Fire hall:
UNDERWRITING
Who is responsible for the care and maintenance of the property?
Insured Neighbor Property Manager Friend/Relative Tenant Other(describe):
How often is the property visited?
Once per month 3-4 times per year Other (describe):
Minimum Rental Arrangements for this property:
Daily Weekly Monthly Yearly Other(describe):
Number of self-contained units/suites: If applicable, is motorized watercraft included in the rental? YES NO
Tenant Details:
Single family per self-contained unit/suite Students – if yes, how many students? Roomers / Boarders
More than 2 unrelated tenants(not students) Rooming House Vacation Rental Other (describe):
Does the owner’s child live in the dwelling / YES NO
Are there any business or farming pursuits on premises? / YES NO
If yes, please describe:
Has this risk been declined, refused or cancelled by another insurer? / YES NO
If yes, please describe:
Will there be any renovations? / YES NO
If applicable, what is the budget renovations?
If applicable, will there be any structural renovations? / YES NO
What are the scope and general details of the renovations:
Is the building slated for demolition? / YES NO
Number of liens/encumbrances/mortgages: 1 2 3 4
Are there any sewer backup losses, insured or otherwise, at this location in the past 5 years? / YES NO
Are there any other types of losses, insured or otherwise, at this location in the past 5 years? / YES NO
If yes, please provide details:
COVERAGES - LIMITS
Dwelling Building: / Detached Structures: / Major Appliances:
Premises Liability: / Rental Income: / Deductible:
Sewer Backup: YES NO Limit Required: / Earthquake: YES NO
INFORMATION REQUIRED UPON BINDING:
Requested Effective Date: / Principal(s) if applicable:
Postal Address: / City: / Prov: / PC:
Loss Payable(s) Name & Address:
PLEASE READ BEFORE SIGNING
This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued. For purposes of the Insurance Companies Act (Canada), any document would be issued in the course of Lloyd’s Underwriters’ insurance business in Canada. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and broker’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.
NOTE: INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER OR POLICY DOCUMENTS.
Signature of Applicant(s): / Date:
Signature of Broker: / Date:
Broker Firm: / Broker AGT #:
Broker Email: / Tel: / Fax #:
Premier Canada Assurance Managers Ltd. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).
** Email application and attachments to - **Vancouver - T 604.669.5211 F 604.669.2667 / Toronto - T 416.365.0444 F 416.365.0446
Rev. Sept 6, 2017